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If denied, the most common reasons are: Insufficient metformin trial duration (submitted 60 days instead of required 90 days) Missing A1C lab result from past 90 days A1C below 7.0% (Ambetter considers diabetes "controlled" and does not approve intensification) Diagnosis code submitted as E11.9 (unspecified diabetes) instead of more specific code A study by the American Diabetes Association (Gabbay et al., Diabetes Care 2024) found that prior authorization denials for GLP-1 receptor agonists were overturned on appeal in 71% of cases when resubmitted with complete documentation
Grant CS
doi: 10.1016/j.nut.2022.111807 15
